MEDICAL HISTORY QUESTIONNAIRE Please answer all the questions below to the best of your ability. Our ability to help you is based, in part, upon the accuracy and completeness of your medical/ophthalmic history and description of symptoms. Name First Last Date MM slash DD slash YYYY Date of Birth MM slash DD slash YYYY How would you like us to address you? Home PhoneWork PhoneCell PhoneAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Social Security # Email Occupation Employer How did you hear of our office? Insurance plan Family member Internet Other OR referred by: May we send them a thank you note? Please list any members of your family who come to our office: Chief reason(s) for visit: Special visual demands (at work/sports/hobbies): Are you interested in getting new eyeglasses today? Preliminary Medical HistoryDo you have any allergies to medications? Yes No Explain: Please list major injuries and/or surgeries you have had: Who is your primary care physician (internist/family doctor)? Are you pregnant and/or nursing? Yes No Please note any personal or FAMILY HISTORY (parents or siblings only; living or deceased) with the following:NoSelfParentSiblingsUncertainCataractCrossed EyesGlaucomaMacular DegenerationRetinal Detachment/diseaseOtherIf other, please specify: Social History:Do you drive? Yes No Have you had visual difficulty when driving? Yes No Do you use tobacco products? Yes No How long? Review of SystemsDo you currently or have you ever had any problems in the following areas:YesNoUncertainFever, Weight Loss/ GainIntegumentary (skin)HeadachesMigrainesLoss of VisionDouble visionDrynessItchingExcess tearingInfection of eye lidChalazion/ styeFlashes/FloatersThyroid DiseaseDiabetesPsychiatricLupus/other autoimmuneAllergies / Hay feverDry throat and/or mouthAsthmaCOPD / breathing problemHigh Blood PressureOther vascular diseaseRheumatoid ArthritisJoint PainAnemiaBleeding ProblemsCancerOtherIf cancer, please specify: Type Status If other, please specify: For ‘Yes’ answers to any of the above or if you have a condition not listed, please explain.List all drugs you are taking including aspirin, oral contraceptives, hormones, over the counter meds or vitamins: Maintaining the privacy of your information is of paramount importance to us as it helps foster confidence, good will and stronger relationships with you, our patients. If, at any time, you have questions or concerns about our privacy practices, please feel free to read our Notice of Privacy Practices. If you have any questions, please feel free to contact us at frontdesk@madisoneyesnj.com. Copies of this Notice are also available upon request.By initialing your name, you agree that you understand our Notice of Privacy Practices/HIPPAI have carefully completed this questionnaire to the best of my ability. I understand that my doctor’s ability to best care for me (or child) is based significantly on the family/personal health history and description of symptoms.Patient/Guardian SignatureDate MM slash DD slash YYYY Doctor’s Signature (after reviewing)Date MM slash DD slash YYYY Optos Ultra-Wide Retinal ImagingDuring the COVID-19 emergency, we are requiring a retinal screening as part of a comprehensive eye exam for these reasons: We are usually able to safely and comfortably examine the interior of your eyes without using dilating eye drops while improving social distancing. We are able to detect eye diseases at an early stage, even before the onset of symptoms. In some cases we will also recommend a dilation of your pupils. There will not be any additional fee charged for pupil dilation. It is much faster than a dilated exam without the annoyance of eye drops or an extended exam with especially bright instrument lights. There isn't blurred or light sensitive vision afterwards. We maintain permanent images to identify change. We are able to detect and manage eye diseases with documentation of change or stability. While the instrument is expensive, we are able to keep the screening fee affordable at $39.Please confirm your acceptance of receiving retinal imaging, below.* Yes, please include the retinal imaging as part of my (or my child's) exam. I understand that there is a fee of $39 that is not covered by my insurance plan. HiddenPatient Name: First Last HiddenSignature:Date: MM slash DD slash YYYY HiddenInitialHiddenInitialHiddenInitial